Home Library Service Application Form

Personal Details

Name

First Last

Date of birth:*

Address

Street Address Address Line 2 Suburb State Postcode

Phone

Email

Borrower No:*

Living Status

Transport Status

Other

I have access to the internet
I receive in-home carer or respite services
I attend out-of-home respite services

Please list any relevant medical conditions and/or physical/cognitive disabilities

Service Requirements

Delivery service options:

Client to collect from:

Instructions for Item Selection

Fiction

Format

Audio Books
Ordinary Print Books
Large Print

Number of Audio Books*

Number of Ordinary Print Books*

Number of Large Print*

Non-Fiction

Format

Audio Books
Ordinary Print Books
Large Print Books

Number of Audio Books*

Number of Ordinary Print Books*

Number of Large Print*

List Subjects

Other

DVDs
CDs
Magazines

Number of DVDs*

Number of CDs*

Number of Magazines*

Any Further Details

Hard/Soft Cover, Size/Weight, etc:

Declaration

I have read/I am aware of Ipswich City Council's Privacy Policy and agree to conform to the rules of Ipswich Libraries and to pay any fines and make good any damages or loss which I may justly be charged. I give permission for any duly authorised Home Library Service Representative to enter the premises of the address given on this form for the purpose of delivering library services.